198

THE LANCET.

LONDON : SATURDAY, JULY 21, 1900.

THE CROONIAN LECTURES ON THE DEGENERATION OF THE NEURONE.

have the highest of all authorities for believingthat "Wisdom is justified of her children." The truth

of the statement must occur to the minds of most of those

who read, or were able to hear, the Croonian Lectures

which Dr. F. W. MOTT has recently delivered before the Royal- College of Physicians of London. They are for the most partthe product of the far-seeing wisdom of the London CountyCouncil in establishing a laboratory with adequate meansfor the investigation of the minute pathology of the

diseases under treatment at their asylum. It is also an

illustration, although not the first, of the wisdom exercisedin the selection of a superintendent, whose diligent use ofthe few years in which he has been at work and his utilisa-

tion of the material which has come under his disposal areconspicuously shown in these lectures. We find, indeed,throughout them abundant traces of the work which madeDr. MOTT’S name familiar before his appointment and which ifurnished the ground on which his appointment was made,but the chief part of their substance consists of the resultsof researches undertaken by him, or under his direction, atthe County Council’s Pathological Institute at Claybury; iand the extent of this, its value, as well as the manner in

which it is presented, must excite the admiration of all thosewho are capable of estimating its worth. I

Originality is the key-note of the presentation which is J

here given to us of the pathology of nervous disease. All J

that is presented with this freshness is not indeed new. I

Many as are the references to the work of others, such, a 1

description of the facts, even in the light of original research, ]must traverse the results previously obtained at more points c

than it has been possible to indicate. But this does not I

diminish the interest of the account or its value to all those c

who are at work on the same subject, and indeed to all those 1

who care to give to the lectures the careful perusal which they 1

require if they are to be perfectly understood. The subject idoes not lend itself to simple statement. The rapid advance 1of neurology has brought into almost colloquial use among 1

experts many terms which are still unfamiliar to the 1

majority and the amount of fact with which the lecturer lecturer

has had to deal has compelled a condensed style which ’.

certainly needs close attention to understand. But the 1

requisite attention will be forthcoming from the readers to (

whom the lectures specially appeal. ’ s

The title of Dr. MOTT’S lectures is alike accurate and 1

misleading. The transformation of our conceptions of the tnervous system involved in the doctrine of the "neuron" ais vaster than is commonly conceived and its wide extent is (

illustrated in the subjects considered in these lectures. It will

be noticed that a final I e " is attached to the word. i

"Neurone" is the French term, but in all other countries, E

and generally in this country, the word "neuron" is t

employed. The addition of the " e is apparently due s

to the persistence of Professor SCHAFER in applyingthe word " neuron " to the axis-cylinder process,

commonly termed the " axon," in opposition to the

general use of the word. Dr. MoTT’s modification of

the term is harmless, but we doubt whether it will be

effective to prevent confusion, or is really required. The

vitality of words is often insusceptible of control, even as

regards their form. The fittest survives, in contempt of

etymology.Even those who have some acquaintance with neurology

might conceive that the title " degeneration of the

neurone" would cover a limited region of the minute

pathology of the nervous system. The perusal of

these lectures will reveal to many for the first time

the extent of the change in our conceptions which is

involved in the new doctrine. The neuron is now per-ceived to be the universal unit of the nervous system,the element of its constitution in all parts, so that the

"degeneration of the neurone becomes contermino thall the processes of degeneration in the nervous system.Not only does the lecturer frankly employ this wide concep-tion, but he includes under the term" degeneration" thechanges which are produced by acute processes as well asthose which constitute the chronic changes to which the

word is often restricted. He is thus able to stretch his net

so widely as to gather in it most of the maladies which arenot the result of obvious external inflammation. The subjectis thus a very large one, and the variety of diseases whichit includes is such as to permit, in respect to many, only aglance at those features which have a relation to the specialsubject.

It is at first somewhat startling to remember that the

doctrine of the neuron is one which is still without actual

proof. It is essentially founded on the discontinuity of thenerve elements which proceed from each single nerve cell.They were formerly thought to unite at their extremities,their nutrition being still believed to depend on their con-nexion with the cell. The union of the divided terminations

of the branches is now doubted by most histologists. Theyare believed to be only contiguous, and that the excitationof the adjacent fibrils is effected by a process of stimula-tion and not continuous conduction. The belief that there

is discontinuity rests on the fact that union cannot be

traced. But the conditions of observation are such as to

leave some investigators still in doubt regarding the

validity of the general inference, although the evidence

has been accepted so generally that pathologists have

no choice but to follow the lead presented to them.

The result affords an explanation of so much that was

before obscure in pathology as to constitute strong evidenceof the truth of the doctrine. This evidence is pre-sented to us by Dr. MOTT with great force and for

the most part with effective cogency. But he reco-

gnises that, though discontinuity is probable, the union

asserted by some does not lessen the general significanceof the " neuron" conception of distinct nutritional units.

While he regards separation of the elemental parts of thenervous system as probable, he considers that it is not

essential to the neuron-conception. He believes that the

terminal branches of the processes may be sometimes

separate and sometimes continuous. Some hesitation

199ENDEMIC ENTERIC ]fEVER.

may be felt in following him here. It is not likelythat both systems obtain in the nerve-centres. On

either view we can understand that secondary degenerationdoes not pass into the nutritional domain of another cell.

But continuity involves simple conduction; discontinuityimplies re-excitation. A new nerve-impulse is excited bythe stimulus of that which reaches the adjacent terminationof the neuron which conducts the afferent impulse, and theenormous augmentation which occurs in many central

processes, as in reflex action, seems more readily thus

explained. It is doubtful if we can assume the existence

of the double relation or the occurrence of the double

process.As an illustration of the fact that at the present time

research is only laying the foundations on which the

future superstructure of knowledge must be built may be

mentioned the discrepancy in the results obtained by stainingthe nerve-cells in artificial cerebral anaemia. In the partsof the brain thus deprived of blood considerable altera-

tions are seen in the cells and their processes when these

are stained by the Nissl and other methods, but when treated

by the chrome-silver method of Golgi both appear perfectlynormal, including the gemmse on the branches. Dr. MOTT

draws the inference that only a few of the cells are stainedby Golgi’s method, and that a large number escape perceptionaltogether in spite of the perfect staining of those whichrespond to the agents. Considering that it is by this

method that the absence of union between branches has been

discerned, that it is on the results obtained by this

method that the doctrine of separate neuron-units entirelyrests, the statement, if true, seems to throw a gooddeal of reputed fact back into the crucible. We have here

an instance of the mental reservation which must be

given to many of the conclusions which are put forward asestablished facts, but which only merit at present pro -visional acceptance.

’

The development of the elements of the central nervous

system is a subject of which Dr. MOTT has given a fullsketch in his introductory lecture. It may at first sightseem anomalous that development forms part of a studyof degeneration. But the reason is obvious, and the onlyobjection that can be taken is to the narrowness of the title

given to that which has so wide a scope. Development anddecay are processes of opposite nature. They underlie the

progress and cessation of the vitality of the tissues. The

one attends the development of functional capacity, the otherits failure. Dr. MOTT has given useful descriptions andillustrations of the remarkable results of the investigationsof ]J’LECHSIG, BECHTEREW, and others, which have estab-lished the differences in time at which the fibres of the

central nervous system acquire their full structural develop-ment by the formation of the myelin sheath. The relative i

time at which this takes place corresponds with the order in i

which the functions are acquired that the structures sub- I

serve. The afferent fibres to the brain develop before thosethat conduct voluntary impulses, and among the earliestto achieve the myelination necessary for function are those I

which conduct impulses from the skin, joints, and muscles ofthe foetus, whose movements must continually generateafferent impulses through the fibres. The researches of HELDhave shown that function exerts a marked influence on this

process of myelination. If one eye is kept closed the

fibres from it develop perfect structure later than those

from the eye which is open, but this is not the case if the

animal is kept in the dark. There is, however, a tendencyto ordered myelination independent of function. The latter

has only a modifying influence, but it can clearly accelerateor retard the process.

It is not practicable to epitomise Dr. MOTT’S condensedsketch of what has been ascertained regarding the histo-genesis of the sheath of Schwann, and the conclusions

at present reached in regard to the development of otherstructures are not yet of clear significance. The specialsubject of the lectures, the degeneration of the neuron

and its varied relationships, must be reserved for notice inanother article.

SEVERAL of the larger and smaller towns in this country-have now come to be known, by their mortality and notifica-tion returns, to suffer to an exceptional degree from entericfever in endemic form. In many of these places it has beenfound impossible to connect causally the continued preva-lence of enteric fever with any of the agencies of infectionto which pronounced epidemics of typhoid fever are com-monly due. Specific pollution of drinking-water, milk,shellfish, ice-cream, and the like may indeed now and thenhave caused an increase of the customary amount of enteric

fever ; perhaps a particular period of sustained fever pre-valence has seemed to have been started by an outbreakwhich was traceable to infected food or drink; but the-

appearance of enteric fever year after year in excessive-

amount has quite certainly not been occasioned by recur-

ring exposure to infection through such agencies. Recentlymuch attention has been given to the part which

may be played by polluted soil in the transmission of

enteric fever infection, and it becomes important to

consider soil in this connexion. In individual instances

the ability to carry infection of soil, using the word in

the narrow sense of surface soil in the neighbourhood of

dwellings, is often almost self-evident. Take the case, so

common in many of our northern and midland towns, wherethere are rows of workmen’s dwellings or cottages in whichthe houses open at the back to a common yard, unpaved,badly drained by open gutters, and served by one or moremidden privies. Who that has seen the way in which slopsare thrown about such yards and the manner in which

refuse may be spilled over the surface when carried to, orremoved from, the common midden can doubt that a case

’

of enteric fever in a row of houses of this sort occasions risk

by way of surface soil pollution to the occupants of the

remaining houses-people who, for example, must needs beliable to carry into their dwellings on their hands or bootssoil upon which infectious matter has been freshly depositedand to inhale infective dust blown about the common yard?’To such and kindred causes, we may well believe, is due

the contrast which medical officers of health have on occasion

been able to demonstrate between a heavy incidence ofenteric fever on particular groups of dwellings where these

sanitary deficiencies abound and its much lighter incidence

upon neighbouring groups of dwellings of similar class-

where opportunities of surface pollution are less.To admit, however, that enteric fever may be locally

200 THE WORK OF THE MEDICAL PROFESSION AND ITS NUMBERS.

spread by way of the diverse and obvious opportunities ofinfection afforded by recently and specifically pollutedsurface soil brings us, it is to be feared, little nearer to

understanding the causation of endemic enteric fever in thecases to which we alluded above. Ability of soil to act, asit were merely mechanically, as a vehicle of infectious

matter which has just been deposited on its surface does notthere meet the case. A satisfactory explanation as due tosoil pollution of the endemic enteric fever to which we referseems to require the further proposition that in certain

circumstances the typhoid bacillus must be capable of

maintaining for weeks and months an active existence in

soil-an altogether different and more recondite question.The difficulties of the subject are well illustrated in

the case of the city of Chichester, where enteric fever inendemic form has been excessively prevalent for a longseries of years since 1870 and has remained prevalent not-

withstanding that in the greater part of the city objection-.able well waters have been replaced by a safer public supplyand cesspools by a modern system of sewers. Dr. THEODORE

THOMSON who, with Colonel MARSH, R.E., has lately madea highly instructive report to the Local Government

Board on enteric fever at Chichester, a review of

which will be found on p. 219, has brought to light manyfacts, positive as well as negative, which taken as a wholesuggest that the explanation must be that there are circum--stances of soil which in Chichester, or in certain parts of it,do in some way favour the viability and active growth of the

typhoid bacillus in the soil. But what are these favouringcircumstances ? 7 Dr. THOMSON shows that there exist in

Chichester many and diverse potentialities of pollution ofsoil by organic matter. But, as he also points out,the mere fact that these potentialities exist is no

explanation for a special proclivity of the typhoidbacillus for Chichester soil. They are present equally,in other towns with no such enteric fever history as

Chichester. If this special proclivity does exist-and in

our present state of knowledge the assumption seems theone most likely to accord with the facts-it is probably,determined by one or other of a large number of obscureconditions which have yet to be studied in this connexion,or by a cofnbination of them. For the subject to be

adequately pursued such factors as the physical and

chemical characters of the soil, the degree of its moisture,the soil-temperature best adapted to the typhoid organ-

ism, and the nature of other organisms in the soil with

which the typhoid bacillus has to compete for its existencemust be reckoned with. Moreover, as Dr. THOMSON

indicates, no investigation, however comprehensive, of soil,in relation to endemic enteric fever would have much

prospect of success if it were restricted to a single locality.’We trust that the Medical Department of the Local Govern-ment Board, to which we already owe so much of our

knowledge of the etiology of enteric fever, may be able toextent its researches in this matter into a wider field and to

-investigate endemic enteric fever differentially in typicalinstances in different parts of the country.

MR. GEORGE EASTES, on assuming the responsible positionof President of the Metropolitan Connties Branch of the

British Medical Association, delivered an address entitled

" Our Numbers and our Work at the Close of the Century,"which is of considerable interest to the medical profession.The general conclusions to which he came on this importantsubject may be summed up as follows :-that there are greatfluctuations within comparatively short periods in the

numbers of the profession and therefore, of course, in the

amount of work for medical men to do ; that there is a

great variety in different parts as to the proportion of

medical men to population ; and that of recent years therehas been a marked tendency to increase in the numbers

on the Medical Register whilst general medical work has,from the operation of many causes, undergone marked

shrinkage in several directions. Mr. EASTES is of opinionthat the work for medical practitioners to do is not

likely to reach its former dimensions except under very

special and temporary circumstances, as in the recent

epidemics of influenza ; and, speaking generally, that theoutlook for medical workers is that they are likely to workunder conditions of ever-increasing competition. Reco-

gnising, perhaps, that he has given rather a pessimisticforecast of the immediate future for medical men, he

does his best later to correct such an impression and

shows that there are some facts on the other side-happyspots where rivalry is not so keen, an ever-widening empirein which the demand for medical practitioners is felt, andthe occurrence of wars in various parts which entail a

sudden and an enormous increase in the demand for medical

men. " Give to us peace in our time " is, we are sure, the

prayer of the medical man as truly as it is that of every

good citizen, but it cannot be denied that times of war

create a demand for medical service.

There are places in the kingdom where, if mere numbersof patients can make practitioners happy, their bliss shouldbe without alloy. Mr. EASTES shows that the proportionof medical men to population in Huddersfield, Norwich,

Hull;and Bolton is very low. The happy practitioners ofthese towns have theoretically over 2000 persons dependentupon each of them for medical attendance. The other

extreme is to be found in Brighton, where in 1881 therewere only 741 persons to each practitioner, and where

now there are only 615. The practitioners of London

come next in paucity of patients, having each barely800 persons to attend. Mr. EASTES tells us that

in South Paddington, where the population has grown lessby 3000 since 1861, the numbers of the profession haveincreased by 20 and the average of persons for each

practitioner can be very few more than 300. The

practitioners of these districts ought obviously to be in

a very bad way, but we are not aware of any facts

which go to show that they are more unhappy or less

prosperous than those in Huddersfield or Norwich. Prob-

ably it will turn out that the mere number of possiblepatients is not the chief factor in the prosperity and

happiness of the profession. It is more important for

medical men to have a number of clients to whose needs

they can do justice and by whom they can be adequatelyappreciated and rewarded. It must be remembered that

these figures are subject to fluctuation in every locality,while the proportion of medical men to their patientsthroughout the kingdom is also constantly changing. For

201CENTENARY OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND.

example, in 1881 it was as high as 1718 ; now it is as low as1393, which is almost identical with the proportion in 1861.Mr. EASTES quotes the late Dr. FARR as having 25 yearsago said that the medical profession would not grow

in proportion to the population and as having feared

that "there was imminent danger that medical atten-

dance might become quite inaccessible to vast numbersof people." Dr. FARR is not the only authority whohas been thus apprehensive. The late Lord PLAYF AIR

used to address warnings to the same effect to those

who advocated bold measures for straitening the gateof the medical profession so that few should enter it.

And undoubtedly it would be possible to carry such measurestoo far. The medical art, it must be remembered, is a

necessity to all classes. The poor and the humble have the

same need of it as the rich and the luxurious classes. But

there is no immediate need for much anxiety on this subject,for the additions to the profession amount to hundreds everyyear. There are, however, some new facts in the problemwhich must not be overlooked. In 1861 there was a largeclass of unqualified assistants who did, roughly perhaps,a third or a fourth of the work of general medical practice.That element has been eliminated by the action of the

General Medical Council or is in course of elimination.

Medical work has been multiplied in various ways by thespecialisation of medicine and by the great developments ofmedical education. The growth of wealth and of commerceinvolves an increased demand for medical service in all its

branches-sanitary, medical, surgical, and special. Then

there is the great development of our empire which throwsso much serious responsibility on us for the welfare of

those by whom it is extended and of the communities

which come by their agency under our rule and care.

Nothing in the last century can exceed the signifi-cance of the events which are happening while we write,teaching us that the millennium is yet distant and

that enormous medical and surgical and sanitary problemswill have to be solved before Africa and China can be

brought within the pale of civilisation as we understand

it.Mr. EASTES thinks that the work of the general practitioner

is much less than it was 30 years ago and that it is likely tocontinue so. The isolation of infectious disease and its treat.ment by the State, the abuse of hospitals, the multiplicationof cheap dispensaries, the growing tendency of the publicto take their advice from consultants and specialists of allsorts, all tend to lessen the work of the general prac-titioner and to lead Mr. EASTES to the conclusion that

the profession is overstocked. Such facts are very importantand call for much consideration, but we do not

regard them as ultimate facts that are to dominate Iand degrade general medical practice for all time. In the ,very nature of things the general practitioner must alwaysbe the first and chief resource of the public needing medicaladvice. Palpable abuses which affect him injuriously willnot last for ever. The general practitioner must meet thecompetition of consultants by dignified protest or by special-ising his own education. He has only to perfect himself asa general practitioner to make himself indispensable in everycommunity and to make the consultant in nine cases out often a luxury.

Annotations."Ne quid nimis."

THE CENTENARY FESTIVAL OF THE ROYALCOLLEGE OF SURGEONS OF ENGLAND.

ON Thursday, July 12th, Sir William Mac Cormac was

unanimously elected President of the Royal College of

Surgeons of England for the fifth time in succession. Noone has previously held the position for so many years,although the late Sir William Savory was President

from 1885 to 1888. Thus Sir William Mac Cormac this

year holds an exceptionally honourable post. The centenaryfestival of the Royal College of Surgeons falls in troubloustimes. One hundred years ago the shadow of the dominationof the First Napoleon, who for a brief space held continentalEurope under his feet was just beginning to obscure thesun of liberty. To-day Europe and the United States ofAmerica stand confronted with the shadow of a far morebarbarous tyranny arising from that race of which 1500 yearsago Attila was the incarnation. But the forthcomingfestival is in reality a peace congress, a living testimony tothe advance of the art and science of healing, and it is

fitting that its chief should be one so lately returned fromministering on the battle-field.

THE TRAGEDY AT PEKING.

AFTER many days of conflicting rumours in which menexpressed opinions and hopes that their reason refused tojustify it has been borne in upon the civilised world thatevery man, women, and child in Peking foreign to China,and every Chinese native known to be in personal or

religious sympathy with them, is dead. What horrors mayhave accompanied those deaths it is best not to conjecture,while the stories that have been circulated as to the way inwhich the women and children met their deaths within thewalls of the British Legation are founded entirely uponimagination. Letters have been received in England speak-ing of revolvers carried by women in anticipation of the

worst, while it is stated upon good authority that

Lady Macdonald, the wife of the British Minister, wentarmed with poison even before the actual outbreak tookplace, knowing that she might need it for herself and forher children. In this course she cannot have been alone,but the actual events of the terrible closing scene are stillunknown to us and may never be other than unknown.There have been massacres before where the natives of

savage countries have wreaked their hatred suddenly uponthe foreigner in their midst, but there has been nothingin history absolutely resembling the tragedy of Peking.England has had experience of terrible outbreaks of

savagery at Cawnpore and elsewhere during the Indian

Mutiny, and we have ever since had thrown in our teeth

by European nations the penalties we exacted in reprisaland in reassertion of our authority. Now each nationof Europe having a political representative at Pekingknows that that representative, with wife, children, andhousehold, has been butchered, knows that every citizen it

has sent out to spread its commerce, to preach its religion,to disseminate its science and its civilisation has either been

slaughtered in the Chinese capital or in some other part ofthe Chinese empire stands in imminent danger of a hideousdeath, and the spirit that is abroad is certainly not one ofmeek forgiveness. Europe will exact a reckoning, though towhom the bill should be presented is, in the present state ofour information, obscure. Every day makes it clearer that